The Saskatoon Police Service must give higher priority to suicide prevention at its detention cells, the jury at a coroner's inquest recommended Thursday.
The six-person jury heard evidence over two days about the suicide of Jasmine Arcand, 34, who hanged herself in a police cell last Feb. 17.
Arcand's booking form was flagged with a large red S for suicide because of a comment she made to the arresting officer and file information showing she had previously attempted suicide while in custody. However, Arcand gave detention staff no indication she was thinking of killing herself and they used their own discretion, as they are expected to do, in deciding not to take any specific precautions with her.
Arcand used her undershirt attached to the toilet flush knob protruding one metre above the floor. She committed the act within three minutes of an officer checking the cells, based on the time code on a video surveillance tape. Staff missed the next 10-minute cell check, so it was 17 minutes before Arcand was found. An ambulance paramedic said brain death occurs after four to six minutes without oxygen.
Trained staff who happened to be present tried to resuscitate Arcand using an automatic defibrillator and CPR but were not successful.
The jury recommended that detainees flagged as suicidal should have "close contact monitoring by a human being" for the first 24 hours after their arrest and should not be left alone in an interview room.
As well, suicidal women should be provided a consultation with a trained person from an appropriate organization, such as a women's crisis centre, jury members recommended.
The greater emphasis on prisoner safety should include training detention staff in suicide risk assessment and prevention, dictating that 10-minute cell checks take precedence over other duties and having one supervising sergeant be dedicated to the detention area on evenings and weekends.
Detention staff also should be required to maintain certification in CPR and be trained to use the defibrillator kept in the area, the jury recommended.
Booking procedures should include a specific form for suicide risk detainees that would become part of the permanent record, they wrote.
Any toilet flush knobs of the type used by Arcand should be replaced with the tapered, suicide-proof design already installed in some cells, they recommended.
Police will review the recommendations and report to the board of police commissioners, probably at the Feb. 10 meeting, Insp. Jeff Bent said Thursday.
"It's obvious the jury took their responsibilities very seriously. All of the recommendations have merit," Bent said.
Video surveillance cameras trained on police cells may give only "an illusion" that police are able to monitor suicidal prisoners, the national director of the Elizabeth Fry Society told an inquest Wednesday into the death of Jasmine Arcand.
The inquest jury viewed a videotape of Arcand, 34, in the Saskatoon city police cell last Feb. 17, when she hanged herself with an undershirt from a toilet flush knob protruding from the wall, about one metre above the floor.
The video revealed a blind spot close to the cell wall near the one-piece toilet and sink unit, which was where Arcand slumped.
Her legs extended into the video image but the picture quality was so poor, a casual observer could have mistaken it for a person using the toilet.
"If you were intently glued to that monitor you would have seen," said Sgt. Donald Yonkman, a major crimes investigator who testified Wednesday.
"Unless you were paying strict attention to it, it could be easily missed."
Kim Pate, of the Elizabeth Fry Society, who testified by telephone from Montreal, said suicidal prisoners may become more anxious if left alone with a camera trained on them, while having a person present in the cell area can comfort them.
She recommended police staff the area with a matron trained in suicide intervention.
The video showed special Const. Viola Yanik checking on Arcand at 11:19 p.m. Arcand then got up and moved to the toilet area. It was not clear what she was doing as she stood facing the toilet-sink unit.
Within three minutes of the cell check, at 11:21 p.m., Arcand's body was in the position in which Yanik discovered her at 11:39.
The police policy requires cell checks every 10 minutes but Yanik was the only female on duty.
She was busier than usual that night because her male counterpart had never worked in the detention area before and she had to show him how to do some tasks or do them herself, she testified Tuesday.
During that time, Yanik booked a prisoner and released another.
The three cell monitor screens on her left showed rotating images of the 36 police cells. Officers have controls to lock a monitor on just one camera but it is not known if that happened in this case, the inquest heard.
It is not unusual for detention staff to miss cell checks, in part because booking in new prisoners requires two people, said Sgt. John Garnet, who supervised the detention and communications centre that night.
The male commissionaire on duty after 4 p.m. and on weekends can check the men but, until Arcand's death, only female officers could check the women.
That procedure has since been changed. Now the commissionaire checks the women if the female officer is not available.
There are still concerns about female privacy, but the need to prevent suicide or notice other health problems takes precedence, Garnet said.
Saskatoon police don't have an official policy for handling suicidal prisoners, Garnet said.
Officers must use their discretion on whether to take precautions with at-risk prisoners because police try to use the least intrusive measures, he said.
Police don't want to take away the clothes and blanket of every inmate who has ever been at risk; the cells are warm but have only thin mattresses on concrete floors, Garnet said.
All of the evidence has been presented. Coroner Alma Wiebe will instruct the jury today before they meet to decide their findings and recommendations.
A special constable with six months' experience and no training in suicide assessment said she used her officer's discretion when she ignored parts of the city police suicide prevention policy in her handling of a woman who hanged herself in a cell in February.
Special Const. Viola Yanik told a coroner's inquest Monday that she did not place Jasmine Arcand in a special Plexiglas-fronted cell and gave her a bedsheet, despite having been told by the arresting officer, Const. Avery Spott, that Arcand had suicidal tendencies.
Yanik said Arcand didn't say anything to her about wanting to kill herself when Yanik booked her, or during four other brief interactions that night.
Yanik said she also missed several, standard 10-minute cell checks of three female prisoners because she was busy with other duties, including booking a new prisoner, releasing another, doing computer background checks and completing paper work.
Yanik found Arcand, 34, at 11:44 p.m. on Feb. 17 with a T-shirt tied around her neck and fastened to the toilet flush handle in her cell. No one else was in the cell with her.
It had been about 24 minutes since Yanik's last cell check. Another prisoner said Arcand seemed normal when they spoke to each other 10 or 15 minutes before Yanik discovered Arcand's body.
Arcand was addicted to morphine and Ritalin and had attempted suicide in the past, her friend, Gordon Mills, testified. Arcand, who had warrants for her arrest for breaching court orders, had told him that day she would kill herself if she ever had to go to jail.
Arcand also told arresting officer Spott that she was "a rat" and that she was "done." At the police station, she asked to talk to a drug officer and asked him if he could get her out of jail if she gave him information.
After that officer said there was nothing he could do, Arcand asked to speak to a lawyer and was put on the phone with a legal aid lawyer, Yanik said. They had a five-minute talk, then Yanik took Arcand to a cell and gave her a sheet, magazines and a cup.
Police said Arcand seemed drunk and "skittish," sometimes moving erratically or waving her hands.
On Feb. 16, the day before Arcand's arrest, Mills had taken her to a hospital emergency ward for help coping with withdrawal symptoms. It had been seven days since she last used morphine. She was given medication "to take the edge off," Mills said.
On the morning of Feb. 17, Arcand visited a doctor at a walk-in clinic and obtained other medication.
The autopsy showed Arcand died from air blockage caused by the ligature around her neck, pathologist Dr. Qinglong Hu said. Toxicology reports show Arcand had therapeutic amounts of two sedatives as well as codeine, acetaminophen, caffeine and a blood-alcohol level of .04. The combination of drugs could have exaggerated their effects, Hu said.
Yanik worked that night with five-year constable Matt Ward, who was new to the area, making Yanik the more experienced of the pair staffing detention. Both were overseen by a sergeant, who was also responsible for the communication centre just down the hall.
Spott's warning, and probably an alert in the local police computer records that Arcand had once tried to hang herself in a police cruiser, had resulted in a large red "S" for suicide risk being written at the top of the booking form for easy notice, Yanik said.
Officers must use suicide precautions if the red S indicates the prisoner has made current comments about harming themselves, Yanik said.
But officers can use their own discretion in applying the precautions if the red S was put on because police records show they were a risk at some time in the past, she said.
Such flags on the older record may no longer be pertinent and police are reluctant to deny prisoners their basic rights, Ward said.
The red S is the same whether the suicide threat is current or old.
The inquest continues today.